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Aine McCaughey, a student at the University of Ulster, Jordanstown, hosted a health fair to promote Action Mental Health, as part of her studies. Here is her story…

Each year, final year students studying BSc Hons Environmental Health at Ulster University Jordanstown organise and participate in a health promotion event. The aim of this event is to create an awareness of a public or environmental health issue. Students are required to show collaborative working either in a team or individually with an organisation from the public, private or voluntary sector to promote awareness of a public health issue which affects the local community.

Starting college can be difficult for some people, moving away from home, starting to live independently, and with the pressures of assignments and exams, it can all be quite overwhelming and difficult.

I chose to promote the issue of mental health for two reasons. Firstly, I felt mental health is a topic that is very relevant in today’s society, as more than half of undergraduate students will experience and present with signs of a mental illness. Also, one in three state they have had suicidal thoughts.

I wanted to create awareness and show the students of Ulster University Jordanstown that if anyone is struggling to cope with daily pressures, there is help available. I wanted to provide them with information about where they can seek support and advice in confidence, and not suffer in silence.

Secondly, I had more of a personal reason to promote mental health as a close family member was diagnosed with an eating disorder about five years ago. Through seeking help from mental health advisors, this illness is now well under control.

I am very pleased and grateful to have partnered up with Action Mental Health’ Callum Clark (AMH Fundraising Officer) and his team have been brilliant in providing me with leaflets, posters and pop-up stands, and I am very grateful and honoured to have raised awareness of this wonderful charity.

The outcome of having this health fair was to promote awareness of different public health issues and to make people aware of problems that affect society, and that help is always available.

Debbie’s mother Pat McLarnon spent years feeling terrified and helpless as she watched her daughter fight her anorexia. Here is her story…

We found out something was wrong with Debbie when her screams woke us in the middle of the night, when she was 17. We found her on the bathroom floor writhing in agony. She wouldn’t tell us what was wrong but when I checked her school bag I found laxatives. She refused to tell me how many she had taken so when I started to guess one, two, three, she nodded her head at 44.

We didn’t fully understand what was going on but we just knew something was very wrong. From that moment our lives were thrown into turmoil. Her younger brother went into her room that night and hugged her and said “Debbie, please don’t die”.

Her whole personality changed. Our daughter had been very bubbly, outgoing and loving but it was almost like our daughter was a stranger. She became very depressed and sad, argumentative and manipulative and we had literally no idea how to help her.

We went to our GP because we wanted to know how we could fix her, but Debbie had hit her self-destruct button and was basically starving herself to death.

Meal times were a battlefield and we tried everything, from punishment to grounding but if we had known then what we know now we could have helped her so much more. We didn’t realise that we were pushing her into the arms of the eating disorder.

When she did eat she would go to the bathroom and make herself sick because not only was she anorexic she also became bulimic. As she became weaker we, as parents, felt powerless and helpless. Every morning my husband Paul and I woke up with a knot in the pit of our stomachs. We were terrified.

In the meantime, she was able to keep up her rhythmic gymnastics and she even competed at the Commonwealth Games when she was 16. It’s part of the sport that you have to be slim and we did talk to her coaches about it, and they were very good, speaking to all the girls about staying healthy, not isolating her on her own, but still, her struggle with anorexia continued. We never knew what weight she got to because she would never let anyone weigh her.

We have come to learn that the longer the illness lasts, the more entrenched it gets and the more negative the sufferer becomes. It’s a very illogical and irrational illness and it got to the point where Debbie said it would be easier for her not to be here at all. Debbie later told us it was like fighting with yourself all the time, with a voice in her head, 24 hours a day, telling her she was disgusting and worthless.

As far as treatment, there was none here in Northern Ireland so we had to battle the services. We wrote to every MP and MLA and got two compliment slips and one letter back. Debbie had to go to London for help, where she saw a therapist for four years. However, it came to the point where the counsellor told us to bring her home: she was so weak she was on the brink of heart failure.

In the end Debbie suffered until her early 20s. Now she would say that it wasn’t about the eating, it was an emotional issue. Not eating, for her, was a symptom and when the problem begins to go away the eating will naturally come back.

Years later my son did a fundraising cycle in America when he read a story on Amy Winehouse’s eating disorder, written by her brother and he was so upset we nearly flew out to be with him. It upset him very much and it was then we realised he still had issues to deal with after watching his sister experience anorexia.

It doesn’t just affect the sufferer, it affects the whole family but thankfully Debbie survived but there was a time when we feared the very worst for her.

Debbie Howard, now a psychotherapist specialising in eating disorders, suffered from anorexia for over ten years. Here is her story ….

I developed anorexia at 12 years old, and suffered with it until my early twenties. It was the most difficult and awful time of my life.

Eating disorders have the highest death rate of all the psychiatric illnesses, and affect 1 in 10 people in the UK. Sadly it is still an illness shrouded in shame, and grossly misunderstood.

So many people say that eating disorder sufferers choose to do this to themselves, or put it down to vanity. But these people are clearly ignorant about this devastating illness.

Your mind is taken over by the most punishing and nasty dictator, who continually puts you down, and dictates your every thought, feeling and behaviour. It tells you that you are not good enough at anything you do, and that you don’t deserve anything you have. It makes you hate yourself, despise yourself, and it makes you feel worthless and useless.

Every time you look in the mirror all you can hear is that voice telling you how disgusting and how fat you are.

You spend hours weighing yourself, pulling bits of fat and planning how to get rid of it, always believing the voice that is telling you that if you just lose another few pounds, you will be happy. But of course, you lose those pounds, and the elusive happiness never appears.

At some level you know that what you are doing is wrong, but the voice is so powerful that it always wins.

If you are wondering how no one knew or why no one did anything, it’s because eating disorders are very secretive illnesses. You become a professional at lying and deceiving people, continually coming up with more and more elaborate ways to hide the fact you haven’t eaten. I managed to hide my illness from my parents for many years.

We tried treatment several times, but the support and understanding from health professionals in Northern Ireland was not there. It was only the life-saving care I received in London that helped me to recover.

Unfortunately there has not been much improvement in terms of treatments since I was ill. Services have increased, however our sickest and most vulnerable are still being sent to London for treatment.

We set up fightED to provide carers courses for those who have a loved one with an eating disorder.

Recovery is a long and painful process, and it is vital that sufferers have a strong support system. Although they may be receiving some treatment, they will spend the majority of their time at home with their parents/carers, so it makes so much sense to educate and empower the carers by teaching them how to best support their loved one and promote recovery. The course teaches parents the tools they need to improve daily life within their family, reducing conflicts, stress and tensions, and well as promoting recovery.

I am a bloke with anorexia and I am not alone. It’s estimated that in the UK;

725,000 people suffer from an eating disorder
Males account for up to a quarter of all cases
There’s been a 66% increase in hospital admissions in the past decade for men with eating disorders

The first ever recorded case of anorexia was a man, I’m not the only one, so, why’s nobody talking about this?

Whenever I tell people I have anorexia they always ask the same thing – ‘when did it begin?’ I’ve heard people describe their ‘journey’ into eating disorders. Mine was more of a diversion. I didn’t realise I was on a subtle detour that’d eventually take me away from myself. I think it was a role in a school play that was one of the first triggers. I had to appear topless, so I decided to lose some weight. As I lost weight I got noticed by this one, incredible, beautiful, amazing girl. I began to associate weight loss with success – if I could be a successful anorexic I thought I could be anything. It became a coping mechanism, a distraction from life. I had exams, deadlines, university applications and all the other insecurities any teenager has. Anorexia gave me something else to focus on, something that was above real life.

It was a gradual slip- something that slowly weighed me down. It’s hard to tell when a social drinker becomes an alcoholic. It’s the same with eating disorders. I forgot the fun of Christmas, birthdays, holidays. I just felt the dread of excess. I couldn’t remember what it felt like to feel comfortable in my own skin. I was never confident or self-assured. I always felt like I was lacking something, not good enough and a loser. My thoughts became poisoned with self-doubt and fear. Yet, I still didn’t realise I had a problem.

Anorexia became my normality, always playing in the background. It took over every aspect of my life – counting calories, constantly anxious, massive mood swings, always cold, linking weight loss with success. Yet, I believed it was the best of me; if you took it away there was nothing left. I was so churned up in it I couldn’t see what it was going on. It took over my life. I didn’t realise how many different aspects of my thinking were entwined with my eating disorder. I read blogs, watched videos and visited forums but no one was talking about a lot of the stuff I was experiencing. So, here are some of the unspoken aspects of anorexia:

Relationship with Food
Just because I wasn’t eating as much as everyone else didn’t mean I wasn’t thinking about food. It was ALWAYS on my mind. I was always totting up calories, thinking up ways to avoid meals and trying to find motivation to go longer before the next snack. I resented the power it had over me. I would feel a fraud any time I ate, I felt weak when I gave into hunger like I was letting myself down.

Self-Doubt
I never felt anorexic enough. It diluted me as a person and gradually took over. Venomous thoughts took over and I changed. I forgot life can be fun. I started taking everything so seriously and let my mind bully me.

Isolation
I hated my own company – always mournful, depressing and down. I wanted to see other people but didn’t want to inflict myself on them. That made me lonely; on the outside of life looking in. I was waiting to be saved from my own life. I was forgotten on the shelf. I wanted a relationship so badly and was convinced I’d end up sad and alone. I locked myself away and turned in on my own mind.

Anxiety
It made me mentally fragile and always anxious. My thinking became binary – everything was perfect or an absolute disaster. I was constantly in a rush for no reason. I felt 2 steps behind everyone else, like I was always missing out.
I began to snatch at life, constantly feeling a knot of fear in my throat.

Physical Impact
I fell out of tune with my body. I still can’t tell when I am hungry. I still hate the feeling of being full. My skin became dry. I was always cold. I’m not talking chilly; I mean gut wrenchingly freezing. It’s like your abs are made of ice packs, your arms are sleeved with coolers. I used to take 2 showers a day just to stop the shaking. I was constantly thirsty and always getting headaches. I have osteopenia – brittle bones – electrolyte imbalance, dangerously low potassium levels, toothache, and on and on.

Masculinity
It’s taken a lot of aspects of my masculinity. The body begins shutting down and conserves energy. So, the brain stops secreting as much testosterone – it’s very power hungry. So if you can identify with any of this, you are not alone. It might be too much to admit it to anyone now, but admitting it to yourself is a first good step. As they say, every journey begins with that first step.

Read more about similar stories at Northern Ireland-based organisation, The Laurence Trust, set up in memory of Laurence Nugent, who died in 2009 at the age of just 24 following a lengthy battle with an eating disorder. https://www.thelaurencetrust.co.uk/

As a person with anorexia I did not realise it had taken control until after about four months. Being very athletic both in school and at my athletic club the weight came off me very fast. It took someone from my childhood who I used to play with to tell me honestly – and he was in shock! He asked ‘what on earth’ had I done to myself.

After this I looked in the mirror and saw for the first time a skeletal face staring back. Don’t get me wrong, family, friends, even teachers tried to make me see but I thought it was not serious until this point. I think I was age 14 or 15 and doing my GCSEs.

As for triggers, with me it was an accumulation of my parents’ threatening divorce; they didn’t realise I could hear in the next room all the hurtful things that were said. I stopped eating at first because I was so upset, not because I intentionally wanted to harm myself. Then it turned into something I could control – with my parents’ arguing I couldn’t stop or control it.

After my childhood friend made me realise the shocking truth, I knew then I needed help. I asked my mum to make me an appointment with my GP who referred me to Dundonald hospital. I still remember having to get into a gown in a cubicle with my mum present; she cried because I had hidden a lot by wearing loose clothes. The doctor asked me if I knew what I had: I was able to tell him I knew I had anorexia and needed help.

Looking back, I remember I knew I needed to help myself and as soon as I put on enough pounds I was allowed home. Between this time though, only family was allowed to see me, like I was being punished. I can’t remember any follow-ups at hospital or with my GP the day I arrived home from hospital my beloved uncle died that same day. I was so angry that I was trying to kill myself. My beloved uncle was taken from everyone he loved, certainly not through choice, and I felt so selfish. I promised myself I would get better for him – otherwise I think I could have slipped through the net and continued getting worse.

I think better follow-up is definitely needed, as well as more specialist care in Northern Ireland. Maybe there is more help these days – I don’t know. Back then, I only saw a dietitian.

I also think a cardboard cut-out of a normal person, as in healthy body weight for their height, should be set beside a cardboard cut-out of an anorexic person: the same height and weight, because with this illness you see everyone else skinnier than yourself, even though people are telling you you have lost weight. It’s a trick of the mind – you never see how skinny you truly are.

It took me about two years to get better, but I also developed bulimia; I was fighting with my mind constantly. Also, it’s hard to deal with eating more, because once you start to eat normally you plump up! And since your body’s metabolism has drastically slowed down, it’s an uphill struggle for a long time to balance your weight and feel healthy. It would have helped to be aware of this!

At my worst, it definitely caused depression. I didn’t want to socialise I turned into a recluse and secretly I wished I would die in a car accident with no one else getting hurt.

As for getting better, I truly believe I aided my own recovery, through realizing I had anorexia and fighting to get better because of my promise to my uncle. If you don’t want to get better, well that could be an impossible fight because it is not easy and it is lonely. In my case I had no one to talk to about my constant battle. I definitely believe people need to see someone who understands the illness as soon as possible – the more it gets a grip of your mind the harder it is to overcome.

As a society we need to encourage our young men and women to love themselves from within and to be confident enough to talk things through.

As much as I love my parents, I just couldn’t talk openly to them; they were very private, and it’s important to have someone close you can talk too.

Strangely I started having body image problems when I was 19. I think it was triggered by poor self-esteem from a bit of trauma in my life. This is where my self-worth really started to dip. I had body dysmorphia for a long time before it developed into a Binge Eating Disorder. My Binge Eating Disorder happened when I started training in Martial Arts. I found myself putting a lot of pressure on myself to be a certain weight to fight and I always thought I should be a certain weight to compete. This started with extreme low carb dieting where I ended up underweight and very unhealthy although at the time I thought I was great and healthy. This was just the beginning. I kept trying to keep a certain weight and focused heavily on foods but this was to take a turn for the worse when I broke my arm in a Jujitsu Competition and because I couldn’t train anymore for a long time as it was a serious break, I started to go into a binge eating cycle. You see, Martial arts helped me out of depression for a while and then after I broke my arm I lost all of that. I was bingeing for a long time and noticed that I was putting on weight which was upsetting me and then I went to eating more for comfort. It was like my crutch for dealing with things.

This happened for years and I ended up double my actual size. I went from a size 10 to a size 22. This was very hard to deal with. My self-esteem was destroyed. At the time I was also on an anti-psychotic medication which didn’t help the weight gain. It has a huge part of it too, which I am glad I’m now off. I knew I had a problem when I found myself feeling really guilty eating a piece of bread or a sandwich. I had this strange thing against bread! It wasn’t just a normal feeling bad for eating something, I got the point where I had self-harmed on my stomach a lot as I was very distressed after eating junk or binge eating on foods. The disgust I felt was nothing like I have ever felt before.

I didn’t really seek help from family as I didn’t feel they would understand and at times I didn’t think I had an eating disorder. I confided in my sister and I think she knew I had a disorder before I did. She has been so helpful and really let me learn that no matter what way I am, I may be big but I am beautiful! That’s always stuck with me. Regardless of your shape or size that doesn’t change who you are. But that isn’t always easy to try and get into your head especially when you have a disorder. My husband has been my rock and I wouldn’t be here without him. He always encourages me to love myself and know that I am ok the way I am. If I want to get healthy then get healthy! Just remember that you need a healthy mind as well as a healthy body. I think that even people who know me and know I have a disorder still don’t understand but I guess that’s not their fault and we need to have more understanding about. The many times I’ve heard people say to me “why don’t you try slimming world”…. The thing is you can’t hide from food, that’s what people don’t understand. We need it to fuel our bodies! Food is everywhere and it’s hard not to think about it 24/7.

I went to my G.P about this several times but there wasn’t much we could do except send me to a dietitian but at this point it was an unhealthy relationship with food and not a diagnosed eating disorder. I was part of psychiatric care and I told them about my issues with food, but because I didn’t vomit or take laxatives there was no help at all for me. I find this disgraceful but I guess there are only so many services they can offer. This is when I went to Action Mental Health and they helped me and recommended Life Therapies in Belfast. I saw them privately for a year. I was expensive but it was worth it. I learnt a lot and I really developed as a person. My advice, is if you can afford it, go to see a specialist in eating disorders as you will learn a lot. If you can’t then look at charity’s and get some support. You cannot do this alone!

I am still battling an eating disorder which is tough. I had been doing really well in the mind-set for a good 8 months but now I have had physical illness happen and it’s kind of triggered my disorder again. In this space of time I lost 5 stone but I have gained it all again and this is the nature of someone with disordered eating.

I think the best advice I could give anyone is to learn to love yourself and don’t judge yourself on how you think you may look, or by what others may say. People are too quick to judge someone on how they look. Learn to connect your thoughts and feelings and learn why you do certain things, learn to eat when you are hungry and really think about what you’re eating and how nourishing it is for your body. Food is Medicine! Do not Diet! Do not restrict yourself! Once you learn to do this you can then learn a healthier way to eat but also by enjoying food.

One thing I would love people to do is think before they speak or think how it may affect that person. You just don’t know what people are going through in their heads or what they are battling. Why should anyone comment on how someone looks? This applies to thin people too. I know a lot of people who hate being told they are too skinny, so it’s all one side of the same coin, so to speak. Another thing is to stop body shaming!

Speak to someone you trust, and if you find that too hard then speak to a charity organisation like Action Mental Health as they will totally understand you and sometimes speaking to someone you don’t know is easier. We can all develop eating disorders regardless of age and gender.

Charli, who is now in her twenties, suffered from bulimia as a teenager. Here is her story.

I never really realised there was a problem until my family got involved. Eating disorders are incredibly selfish and you tend to be so wrapped up in what you’re doing that you don’t realise what you’re doing to yourself and the people who love you.

Mine began as a result of two different things: firstly, I have a hormone imbalance and when puberty kicked in I put a lot of weight on and was bullied mercilessly for it, and secondly, it was an element of control in my life when I felt overwhelmed.

My bulimia started slowly. At first it was just making myself sick after meals, then it was purging, and by the end I would chew food but spit it out before I swallowed it. That’s how I was caught out. My brother went to the bathroom after I’d used it and I hadn’t flushed the chain properly.

He and my mum knew there was something wrong but because I’m naturally quite a big girl, broad in my proportions, I never got really skinny or ‘looked anorexic.’ That was something in and of itself that fed my disorder. I have body dysmorphia and really struggled to understand my body and how I looked. It’s also very common for people to have eating disorders and never be diagnosed or receive treatment.

I know lots of girls who have eating disorders. But in our society, if you’re not rake skinny you’re not taken seriously and it’s hard to get the help that you need. I was very ill and was starving myself to the point I’d pass out and my periods had stopped, but I mostly got compliments from people about how ‘healthy’ I looked.

I never got to a GP. The reason I got help was because my mum and brother sat me down and talked to me about what was going on and I realised how my behaviour had affected them. My mother also suffered from bulimia (hers was a control-centred disorder when she was in her early twenties) and when she told me she was horrified that she had somehow pushed me to it. My mum’s my hero and when I realised how hurt and scared she was I immediately agreed to get help. She found a youth counselling service and paid for me to have weekly sessions to help deal with my problems.

As a single parent with little money and very little help from my father, I understood completely the sacrifices she made to send me to those sessions and so I took them seriously and wanted to get better for her.

Once you have an eating disorder it never goes away. You live with it for your whole life, even if you never go down that path again physically. I still struggle with it every day, especially because my hormone imbalance makes weight management difficult. In times of extreme stress it hits me incredibly hard. When I sat my final undergraduate exams I slipped up and fell off the wagon, as it were. But my boyfriend helped me through it and luckily he helps me through it every day.

Recovery is all about surrounding yourself with the right people. At school my friends almost loved the fact that I had an eating disorder. For them it was a cool source of teen drama and they almost encouraged my behaviour. I surround myself with only a few people who understand my past and know my triggers. My best friend, Connor and my mum tend to know I’m struggling before I realise it myself. They tell me when I’m becoming obsessive and help me to work my way out of the mindset that drags you back to it.

Anyone who worries that they might be developing an eating disorder should confide in someone that they trust straight away. There’s a lot of good help out there that’s available now that wasn’t when I went through it. Giving the control to someone else helps. My mum and I sat down and worked out a carefully planned food and fitness plan so I could still feel in control but without the need to purge or hurt myself.

Society needs to understand that eating disorders aren’t only the extreme cases of anorexia that lead to hospital stays or inpatient treatment, but they are also the unhealthy attitude towards food that leads to unhealthy eating patterns.

My cousin had anorexia nervosa which was caused when her family moved home from Italy and she started a new school at age 13. Seeing her go through what I did to the extreme made me understand how bad the choices I’d made were. She was admitted to hospital and was there for 6 weeks. I spent a month of my summer holidays with her in the hospital, helping her to get back to the person she was underneath the disorder.

Hers was never about weight and she’s never had dysmorphia, hers was all about control and because of that it was a slow recovery but one that’s not troubled her as much since. She still lives with it of course, and in times of extreme stress she panics, but she’s doing really well.

Firstly by way of introduction, we’ll just clarify what is meant by an Eating Disorder, dispel a few myths and look at the statistics available so we can have a picture of just how wide spread Eating Disorders are and the effect they are having in our local community.

Please get in touch if you want to share your experience – comms@amh.org.uk and follow us on Twitter and Facebook @amhNI.

What is an Eating Disorder

The most common eating disorders are:

anorexia nervosa – when you try to keep your weight as low as possible by not eating enough food, exercising too much, or both

bulimia – when you sometimes lose control and eat a lot of food in a very short amount of time (binging) and are then deliberately sick, use laxatives (medication to help you poo), restrict what you eat, or do too much exercise to try to stop yourself gaining weight

binge eating disorder (BED) – when you regularly lose control of your eating, eat large portions of food all at once until you feel uncomfortably full, and are then often upset or guilty

OSFED is the most common, then binge eating disorder and bulimia. Anorexia is the least common.

What causes eating disorders?

We don’t know exactly what causes eating disorders.

You may be more likely to get an eating disorder if:

you or a member of your family has a history of eating disorders, depression, or alcohol or drug addiction

you have been criticised for your eating habits, body shape or weight

you’re overly concerned with being slim, particularly if you also feel pressure from society or your job – for example, ballet dancers, jockeys, models or athletes

you have anxiety, low self-esteem, an obsessive personality, or are a perfectionist

you have been sexually abused

Dispelling the Myths

Eating Disorders are not primarily about food and weight

People can and DO recover

Eating Disorders can affect anyone of any age, gender or background

Although an Eating Disorder is a complex mental health condition, in its simplest, it is about using food as an emotional tool. For the person with an eating disorder, controlling food and the body is their way of relieving distress or managing their emotions and achieving some degree of control over their life. Their eating disorder provides them with a sense of safety.

Eating disorders in particular are highly stigmatised, with people commonly dismissing the condition as a ‘diet fad’, a ploy for attention, or simply as ‘normal’ behaviour.

Men and women of any age can get an eating disorder, but they most commonly affect young women aged 13 to 17 years old – but even as young as eight.

Eating disorders don’t happen overnight. They typically progress slowly, and are often triggered by something seemingly innocent, such as the desire for a child to lose a few pounds, or encouragement to over-train for a sport.

Eating disorders include extreme emotions, attitudes, and behaviors surrounding weight and food issues. They may be coupled with high levels of anxiety, or with specific anxiety disorders like OCD.

The Stats

Each year in Northern Ireland, some 50-120 people develop anorexia nervosa and around 170 people develop bulimia nervosa. There are around 100 admissions to acute hospitals for eating disorders annually. This excludes patients requiring inpatient treatment outside Northern Ireland. Between July 2012 and September 2015, the HSC Board advised that 52 referrals were
made for ECRs to other hospitals or clinics in Great Britain or the Republic of Ireland. Two of these were young people under the age of 18. – The Regulation and Quality Improvement AuthorityAssurance, Challenge and Improvement in Health and Social Care, Review of Eating Disorder Services in Northern Ireland, December 2015.

While over 700,000 women and men in the UK have a diagnosed eating disorder at any one time, research suggests that this number vastly underestimates the true size of the problem in the UK with estimates suggesting that up to 80% of individuals who screen positively for having an eating disorder have never accessed help or support.

Eating disorders claim more lives than any other mental illness, one in five of the most seriously affected will die prematurely from the physical consequences or suicide. But one of the most harmful symptoms of an eating disorder is SILENCE, we want to encourage those affected to speak out for support and know that a listening, understanding and confidential ear will be here to support you towards recovery.

With research suggesting that as many as 1 in 20 people will develop an eating disorder over their lifetime it’s important we raise awareness of this mental health condition throughout our community and provide much needed support and training within this area of mental health